I am a writer, scientist, and educator who focuses on how we think about how we think. Here you'll find reports on the latest brain-related research, analyses of the social and biological aspects of brain health, and some opinionating. My work has appeared at the New York Times Motherlode blog, Forbes, Slate, Grist, The Scientist, Scientific American guest blogs, MIT Tech Review, American Scientist, The Scientist, Backpacker, Texas Parks and Wildlife Magazine, and in other local and regional publications.

The author is a Forbes contributor. The opinions expressed are those of the writer.

Should Children Take ADHD Drugs -- Even If They Don't Have The Disorder?

The discussion is at least twice as old as my 10-year-old son with attention deficit/hyperactivity disorder (ADHD): Should we medicate children with ADHD drugs just to keep order in the classroom or help the child be competitive among peers? I know it’s at least 20 years old, this argument, because it was a subject of almost daily discussion in teachers’ lounges when I taught middle school in the ’90s, and because the tension among teachers, parents, and the children taking the drugs often spilled into the hallways. And this all was in private schools. I can only imagine that the intensity was multifold in the public school setting.

The age of a controversy, as anyone in public health can tell you, doesn’t necessarily diminish its relevance or the passions it inspires. That’s why this piece by Alan Schwarz in the New York Times has yielded some serious angst in many circles. It takes as its center a doctor who, Schwarz writes, prescribes ADHD drugs off-label for children he avers don’t have ADHD, saying that because the schools won’t do what they should to help low-income kids learn, we “have to modify the kid.”

This physician, Dr. Michael Anderson, also happens to be among those who dismiss ADHD is a “made-up” disorder, in spite of considerable evidence linking specific gene variants to ADHD and suggesting a large genetic component [PDF]. He’s another contributor to the ever-present backlash against ADHD as a diagnostic entity, but instead of blaming lazy parents this time, he blames the school system, one that neglects children whose behaviors in a classroom might be ameliorated by an appropriate environment, in the absence of which, medications have to do the job. He certainly has a point … to a point.

His attitude about ADHD, though, is what’s fueled the concerns I’ve seen about this article, particularly from people who love someone with ADHD. ADHD, you see, has a terrible reputation, one that suffers in large part because of abuse of drugs used to treat the condition. Many, many drugs exist that people use off-label to self medicate or boost performance. But I can’t think of drugs whose abuse stigmatizes the disorder for which they’re actually used as much as ADHD drugs do. And abuse of ADHD meds is inextricably linked with skepticism about the ADHD diagnosis: neurobiological conditions that overlap with the typical zones of behavior suffer from this kind of skepticism, but ADHD stands out. Blame for the drug abuse and diagnostic overuse heaps on doctors, parents, teachers, society, and people diagnosed with it. Are any of these groups to blame for the existence of ADHD? Generally, no. But some are to blame for its bad reputation and the abuse of the drugs used to treat it.

Drugs to treat ADHD work, as I’ve written before, but they carry known risks, and we still won’t know for some years what the long-term outcomes are following their use in childhood. Schwarz describes in his article a child taking the medication Adderall who begins see people and hear voices that aren’t there, a rare side effect of the drug. That child is no longer on Adderall and instead is now taking Risperdal, a psychotropic medication with indications for schizophrenia and irritability associated with autism. It is not an “ADHD drug,” and it too carries potential risks that need to underweigh its benefits to warrant its use. One of the primary benefits of ADHD medications for children with the condition, in addition to the academic, is that the perceived improvement in behavior can translate into better social relationships and a reduction in the constant messages that they receive that they are a “bad person.” Whether or not they ultimately absorb that message as an inherent part of themselves remains to be seen.

In addition to prescribing Adderall to this boy, Anderson also prescribed it to two of the child’s siblings. In the article, the parents think that this prescription is an off-label use of Adderall, and the article holds up these two children as examples of using this drug to improve behavior and classroom performance in the absence of an ADHD indication. Yet Anderson then is reported as saying that all of the children for whom he has prescribed ADHD medications have met the criteria for ADHD, including these two children, whose parents don’t seem to know that. In other words, this story is about children who meet the ADHD criteria receiving drugs to treat ADHD and experiencing benefits, not about a broader use of ADHD drugs off-label to level the classroom playing field.

Forbes writer Matthew Herperblogged today that the NYT piece “hits the problem with ADHD drugs: they work.” Yes, they do. They work for ADHD, based on the only examples provided in this article, not more broadly for low-income children who just need more drug-induced focus in the classroom. Whether the doctor “rails” against the diagnostic criteria or not, the children taking–and responding to–Adderall in this article all met the criteria for an ADHD diagnosis. Indeed, low-income children are most likely to meet the diagnostic criteria for ADHD yet least likely to receive appropriate pharmaceutical intervention for it. So whether he likes it or not, the doctor, by applying existing criteria, might have appropriately identified and treated children with ADHD who otherwise would have fallen through the cracks.

That doesn’t mean that we’re not still facing a brave new world in which college students pop Adderall for exams or driven high-school students are torn between the med boost and simply making it on their own, as they are. As Herper notes, there’s an important national conversation to be had around ADHD drugs and their off-label use to level the field or give an advantage. In his post, Herper asks, “Can we avoid a world in which thinkers are forced into brain-doping in the same way athletes have been pushed to chemically modify their bodies?” In neither case do we know the long-term positive or negative outcomes for the individuals being doped, whether for brain or brawn. I can’t speak about athletes, but as someone who has taught thousands of students from ages 5 to 65, I can say this: What we, in our short-sightedness, view as a childhood deficit because of its interference with classroom function can often yield our most beautiful manifestations of human thought and diversity later in life. Do medications help children with ADHD? Yes, they do. But … and I think this is the real point of the Schwarz piece, even as the examples simply bear out efficacy of ADHD meds for ADHD: We can’t look to the children for what needs “fixing.” For that, we must look to ourselves, and the depth and breadth of our problems with education in this country aren’t something even a full-scale, population-wide pill can fix.

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Risperdal reproached. Same saga here as Eli Lilly Zyprexa. Johnson and Johnson is a trusted brand we associate with babies. Risperdal,Zyprexa,as well as the other atypical antipsychotics, are being prescribed for children, even though this is an unapproved, off-label use. An estimated 2.5 million children are now taking atypical antipsychotics. Over half are being given them for Attention Deficit Hyperactivity Disorder,many of these foster children. Weight gain, increases in triglyceride levels and associated risks for (life-long) diabetes and cardiovascular disease. Eli Lilly made $67 BILLION on Zyprexa! *Tell the truth don’t be afraid* Daniel Haszard FMI http://www.zyprexa-victims.com

Thanks for commenting. When I taught middle school, as I noted in the post, there were tensions about using ADHD drugs. The kids seemed to dislike them and would put themselves on “holiday” without telling anyone. Teachers were mixed; some wanted specific impulsive/outbursting children on some meds while others advocated classroom accommodations. Parents were also mixed and struggled with their own inner tensions about making choices for their children that, like most choices we make for our children, have unknown long-term consequences.

I do agree that the best teachers my middle son has had are those who don’t teach only one way and who recognized his gaps and mitigated them through real, effective classroom accommodation. I’d definitely like to see more of that.

As a parent of an ADHD child (now an adult)… I have been throught the ropes and must comment on this article. 1st… ADHD is a REAL condition that has REAL concequences for those diagnosed with it. There are however so many people, parent, teachers, etc that abuse this disagnosis that they have given the children that really do genuinely have this condition a bad name. Our schools teachers… not all of them are over burdened… anything that will make a kid sit still in class is all the better. When my son was first diagnosed in the 2nd grade, I actually had the learning support teacher try to shove down my throat that all would be well once we put our son on medication. She wasn’t interested in talking about behavioral and edicational modifications, how we as the parents could team with the teacher and the school to come up with a comprehensive plan to provide the best enviroment to help him not only at school but at home… she just wanted him to sit down and shut up in class. Praise the Lord that we had a wonderful classroom teacher that was willing to work with us. When I turned the tables on the learning support teacher and explained to her that my first course of action was not to medicate my child but to find and overall approach that would help him succeed… she snidely commented that maybe I should be teaching a parenting class. I used to work at a doctors office and we used to actually have parents call in and ask to have their kids put on Ridalyn (sp?)…. lazy parents that weren’t interested in parenting their child… again.. they just wanted to medicate them and have them sit down and shut up…. ADHD does not discriminate across income levels. To say that low-income children are more suseptable to this condition or required additional support or don’t get the support they need…. you can place the blame squarely on the parents for that one. Not all low-ioncome parentws are lazy but the ones that are…. give a bad name to all of them. Gone are the days that the majority of parents gave a damn about their kids education. I think that parents like myself are not the norm but the exception to the rule these days. Bottom line… ADHD is a condition that is REAL… requires a multiplatform approach (including behavioral, ecucational modifications and in some cases medciation) and medication alone will not fix the problems associated with it. Schools, teachers and parents need to get a grip… stop trying to medicate kids into submission and deal with the broader issues at hand… trying to do everything we can to helpo a kid succeed.

I don’t think stimulant drugs will really genuinely help anyone without at least some ADHD symptoms. I have an ADD-NOS dx but have stayed away from stimulants, because I don’t think the benefit would outweigh the risks. I did the same for my daughter, who is ADHD. We’re both on Straterra. I knew kids in high school that would buy the medication off others because of the way it made them feel (of course they often ground it up and snorted it), but it didn’t help them any in school. What happens more often, I think, is kids that are doing reasonably well in school, don’t get the diagnosis, because of the stigma associated with it. I’ve had people try to tell me my daughter isn’t ADHD, and is Asperger’s instead, because she is so bright, but really, a person with ADHD can be smart, and many are. She actually got treatment and an IEP until 7th grade, because her relatively mild adhd – inattentive type and anxiety caused meltdowns when she was younger – a lot of her friends with similar symptoms, but no meltdowns, had a harder time getting diagnosis, treatment, and support at school.

(also coffee – a different kind of stimulant – which often helps people with ADHD focus – just makes me less focused and more hyperactive – is another reason I’ve personally avoided prescription stimulants.)

Hi Emily: One point that I don’t see mentioned here is that a prime reason for much of the doubt about ADHD is how it is diagnosed and what we know about the causes of ADHD. One researcher I recently spoke with called it “sloppy.” Here’s a piece I wrote as a consumer-parent, talking about why ADHD still needs work: http://budurl.com/kga3

Certainly some of the children diagnosed and tested show gene variants, but we don’t use genetic tests to diagnose — they’re too expensive.

The blog post above references 50 things that can cause the behavior that we identify (and drug) as various forms of ADHD. And how can we double-check to make sure that the ADHD diagnosis is correct? I’ve followed this for almost a decade. In the “olden days,” consumers were assured that if the drug worked on behavior, then that meant that the child had ADHD.

Of course now we have articles talking about how perfectly mainstream students are drugging themselves with ADHD meds to perform better, so the “if it works, you were sick” canard isn’t as believable.

Far better, perhaps, to treat ADHD as what it really is in most cases:symptoms. If your child is displaying ADHD symptoms that are negatively affecting their life, certainly you should take advantage of ADHD meds. But it doesn’t mean that you shouldn’t also look to behavioral or neurodevelopmental therapies to help your child grow past this point in time. Doesn’t that sound more reasonable?

Unfortunately occupational therapists don’t have a billion dollar lobbying business, and THAT goes to the heart of consumer distrust.

I find mixed results about over- and underdiagnosis of ADHD, and it’s variable by population.

I didn’t argue for using genetic testing; I pointed out that one can’t find links between gene variants and a large heritability factor for a diagnosis and then dismiss that diagnosis as “made up.” That doesn’t compute.

I’ve long argued that we should focus on symptoms to mitigate gaps rather than use wholesale labels.

The Scientific American article of mine that I linked above delves into the issues of medication and behavioral therapies, etc., more deeply, including some specifics of what we’re doing for our middle son, who has severe impulse control and inattention problems. That is here: http://blogs.scientificamerican.com/guest-blog/2012/02/23/adhd-backlash-to-the-backlash/

I don’t argue that ADHD or any diagnosis that overlaps typical human behavior doesn’t have subjectivity and fuzzy areas–a human diagnosing a human with a neurobiological or behavioral condition is naturally open to all kinds of subjective interpretation. What I dislike about the treatment of ADHD in the news media is the wholesale indictment of it as a “faux” condition or “condition du jour” in ways that elide the genetic contribution and make it seem that all people with ADHD have terrible parents or are oppositional, poorly behaved children (my son is not) rather than people with serious impulse control problems and profound inattentional difficulties. I don’t mind evidence-based presentation of data about ADHD, difficulties in applying criteria, discussions about cost-benefits of meds and other interventions, abuse of ADHD drugs, etc., as long as they’ve got data to support the assertions and don’t paint all people with ADHD with same broad, negative brush. These are people they’re writing about, not labels.